Prostate cancer is the most common cancer among American men, with the American Cancer Society (ACS) estimating approximately 299,010 new cases in 2024. More than 60% of prostate cancer diagnoses occur in men age 65 and older, with the average age at diagnosis being 66. While these statistics are sobering, there's also reassuring news: prostate cancer is often slow-growing, and most men diagnosed with prostate cancer do not die from it. The National Cancer Institute (NCI) reports that the five-year relative survival rate for all prostate cancer stages combined is 97%, and for localized and regional prostate cancer, the five-year survival rate approaches 100%.
Understanding Prostate Cancer Biology and Risk Factors
The prostate is a walnut-sized gland located below the bladder and in front of the rectum. It produces fluid that forms part of semen. Prostate cancer develops when cells in the prostate gland begin growing uncontrollably. Most prostate cancers are adenocarcinomas, developing from gland cells that produce prostate fluid. According to the NCI, prostate cancer growth rates vary dramatically—some prostate cancers grow very slowly and may never cause problems during a man's lifetime, while others are aggressive and spread quickly to other parts of the body.
This biological variability creates significant challenges for screening and treatment decisions. Many men harbor microscopic prostate cancers that will never cause symptoms or death. Autopsy studies show that approximately 50% of men in their 70s and 80s who die of other causes have histologic evidence of prostate cancer, yet most of these cancers never caused clinical problems. This phenomenon of 'overdiagnosis'—detecting cancers that would never have caused harm—underlies much of the controversy surrounding prostate cancer screening.
Several factors increase prostate cancer risk. Age is the strongest risk factor—prostate cancer is rare in men younger than 40, but risk rises rapidly after age 50. According to the ACS, approximately 6 in 10 prostate cancers are diagnosed in men aged 65 and older. Race significantly affects risk: African American men have the highest prostate cancer incidence in the world and are more than twice as likely to die from prostate cancer compared to white men. Asian American and Hispanic men have lower prostate cancer rates than non-Hispanic white men.
Family history substantially increases risk. Men with a father or brother diagnosed with prostate cancer have more than twice the risk of men without affected family members, and risk increases further with multiple affected relatives or relatives diagnosed at young ages. Inherited genetic mutations including BRCA1 and BRCA2 (associated with breast and ovarian cancer) also increase prostate cancer risk, as does Lynch syndrome. The NCI recommends that men with strong family histories discuss genetic testing and enhanced screening with their healthcare providers.
The PSA Screening Controversy Explained
Prostate-specific antigen (PSA) is a protein produced by both normal and cancerous prostate cells. The PSA test measures the level of PSA in blood. Elevated PSA can indicate prostate cancer but also occurs with non-cancerous conditions including benign prostatic hyperplasia (BPH, enlarged prostate), prostatitis (prostate inflammation), and urinary tract infections. Age-related prostate enlargement normally raises PSA levels, complicating interpretation in older men.
The controversy surrounding PSA screening centers on whether it saves lives sufficiently to justify potential harms. Two large randomized controlled trials produced somewhat conflicting results. The U.S. Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, which followed 76,000 men for over a decade, found no significant difference in prostate cancer mortality between men randomized to annual PSA screening and those receiving usual care. However, the study had limitations including high rates of PSA testing in the control group.
The European Randomized Study of Screening for Prostate Cancer (ERSPC), which followed 182,000 men across seven European countries, found that PSA screening reduced prostate cancer mortality by approximately 20% after 13 years of follow-up. However, this benefit came at substantial cost: 1,410 men needed to be invited for screening and 48 additional cancers needed to be detected to prevent one prostate cancer death. According to the NCI's analysis of these trials, the absolute reduction in prostate cancer death was small—approximately 1.3 fewer deaths per 1,000 men screened.
The harms of PSA screening are well-documented. First, false-positive results are common. According to the ACS, about 25% of men with elevated PSA don't have prostate cancer. False positives lead to anxiety and often trigger prostate biopsies. Second, prostate biopsy itself carries risks including pain, bleeding, infection (occurring in about 1% of biopsies), and temporary difficulty urinating. Third, and most significantly, PSA screening leads to overdiagnosis—detecting cancers that would never cause symptoms or death.
The NCI estimates that PSA screening leads to overdiagnosis in 20-50% of screen-detected cancers. This overdiagnosis can trigger overtreatment with surgery or radiation causing side effects including erectile dysfunction (occurring in 30-70% of men depending on treatment and baseline function), urinary incontinence (affecting 10-20% of men long-term after surgery), and bowel problems (particularly after radiation). Many men treated for prostate cancer that would never have caused problems experience lasting quality of life impairment without survival benefit.
Current Screening Recommendations for Men Over 65
Given the complex balance of potential benefits and harms, major medical organizations offer nuanced, risk-based screening recommendations rather than universal guidance. The U.S. Preventive Services Task Force (USPSTF) recommends that for men ages 55-69, the decision to undergo periodic PSA screening should be an individual one based on patient values and preferences after discussion with their clinician about benefits and harms. For men age 70 and older, the USPSTF recommends against PSA-based screening for prostate cancer, concluding that potential benefits do not outweigh the harms in this age group.
The American Cancer Society recommends that men have an opportunity to make an informed decision about prostate cancer screening after receiving information about uncertainties, risks, and potential benefits. The ACS advises this discussion should occur at age 50 for men at average risk who are in good health and have at least a 10-year life expectancy, at age 45 for men at high risk (African American men and men with first-degree relative diagnosed with prostate cancer before age 65), and at age 40 for men at very high risk (multiple affected first-degree relatives at young ages). Critically, the ACS states that men without symptoms who don't have a 10-year life expectancy should not be offered screening.
The American Urological Association recommends shared decision-making about PSA screening for men ages 55-69 at average risk and for younger high-risk men. For men age 70 and older, or any man with less than 10-15 year life expectancy, routine PSA screening is not recommended.
For men over 65 considering PSA screening, several factors should guide decision-making. First, honestly assess your overall health and life expectancy. Men with serious heart disease, lung disease, diabetes complications, kidney failure, or dementia have limited life expectancy and are unlikely to benefit from screening. The NCI emphasizes that life expectancy, not chronological age, should drive screening decisions. A healthy 75-year-old might reasonably expect to live 15+ more years and could benefit from screening, while a 68-year-old with severe heart failure has limited life expectancy and wouldn't benefit.
Second, consider your prostate cancer risk. African American men and men with strong family histories face higher risk and might derive greater benefit from screening than average-risk men. Third, evaluate your personal values and preferences. Some men find the uncertainty of not knowing their cancer status intolerable, while others prefer avoiding the potential harms of screening. Fourth, consider your PSA history. Men who've had consistently very low PSA levels (below 1-2 ng/mL) through their 60s have very low likelihood of developing life-threatening prostate cancer and might reasonably stop screening.
Active Surveillance: Monitoring Low-Risk Cancer
Active surveillance has emerged as an evidence-based management strategy for men with low-risk prostate cancer, offering an alternative to immediate treatment. The NCI reports that active surveillance involves closely monitoring cancer with regular PSA tests, digital rectal exams, repeat prostate biopsies, and sometimes MRI scans, without immediate treatment. Treatment is initiated only if the cancer shows signs of progression.
Multiple large studies demonstrate the safety of active surveillance for appropriately selected men. The ProtecT trial, published in the New England Journal of Medicine, randomly assigned men with localized prostate cancer to active surveillance, surgery, or radiation. After 10 years, there were no significant differences in prostate cancer-specific mortality among the three groups—approximately 1% of men in each group died from prostate cancer. However, men who underwent immediate treatment experienced significantly more side effects including erectile dysfunction and urinary incontinence.
According to the ACS, ideal candidates for active surveillance include men with low-risk prostate cancer characterized by PSA less than 10 ng/mL, Gleason score 6 (3+3) on biopsy, cancer confined to the prostate (stage T1c or T2a), cancer present in a limited number of biopsy cores, and no individual biopsy core showing extensive cancer involvement. Men with intermediate-risk disease meeting certain criteria might also be candidates for active surveillance.
Active surveillance protocols typically involve PSA testing every 3-6 months, digital rectal examination every 6-12 months, repeat prostate biopsy 6-12 months after diagnosis and then periodically (every 1-5 years depending on protocol), and prostate MRI in many protocols to monitor tumor characteristics. If surveillance detects cancer progression—rising PSA, worsening biopsy results, or concerning MRI findings—treatment options are discussed.
The major advantage of active surveillance is avoiding or delaying treatment side effects. The NCI reports that approximately 50% of men on active surveillance remain untreated at 10 years, avoiding treatment-related sexual, urinary, and bowel dysfunction. When treatment eventually becomes necessary, it's generally still effective because most prostate cancer progression during surveillance remains localized and curable.
The psychological aspect of active surveillance varies among men. Some tolerate the knowledge that they have cancer without immediate treatment, while others experience significant anxiety requiring transition to active treatment for peace of mind. Research shows that most men on active surveillance adapt well psychologically, with quality of life scores similar to or better than men treated immediately.
Treatment Options: Surgery, Radiation, and Hormone Therapy
When treatment for prostate cancer is necessary—either at diagnosis or after active surveillance progression—several effective options exist. Radical prostatectomy surgically removes the entire prostate gland and some surrounding tissue. This can be performed through traditional open surgery, laparoscopic surgery, or robot-assisted laparoscopic surgery (most common currently). The ACS reports that radical prostatectomy is most appropriate for men with cancer confined to the prostate, life expectancy exceeding 10 years, and good baseline health.
Surgery effectively treats localized prostate cancer, with 10-year cancer-specific survival rates exceeding 95% for low and intermediate-risk disease. However, side effects are significant. According to the NCI, erectile dysfunction occurs in 30-70% of men after prostatectomy, depending on age, baseline sexual function, nerve-sparing technique, and surgeon experience. Urinary incontinence affects virtually all men immediately after surgery, gradually improving over months. Long-term, approximately 10-20% of men experience persistent bothersome incontinence requiring pads. Rare complications include surgical risks (bleeding, infection, blood clots) and urinary stricture.
External beam radiation therapy uses high-energy beams to kill cancer cells. Modern techniques including intensity-modulated radiation therapy (IMRT) and image-guided radiation therapy (IGRT) precisely target the prostate while minimizing radiation to surrounding tissues. Treatment typically involves daily sessions over 8-9 weeks. Stereotactic body radiation therapy (SBRT) delivers higher radiation doses over fewer treatments (typically 5 sessions), offering convenience without compromising effectiveness.
The ACS notes that radiation therapy outcomes for localized prostate cancer are similar to surgery, with 10-year cancer-specific survival rates exceeding 95% for low and intermediate-risk disease. Side effects differ from surgery. Erectile dysfunction develops gradually in 30-50% of men over 5 years post-radiation. Urinary symptoms including urgency, frequency, and nighttime urination occur in many men during treatment, usually resolving within months. Long-term urinary incontinence is less common than after surgery. Bowel problems including diarrhea, urgency, and rectal bleeding affect some men, typically mild and temporary but occasionally persistent.
Brachytherapy (radioactive seed implants) places radioactive pellets directly into the prostate. Low-dose-rate brachytherapy involves permanent seed implantation, while high-dose-rate brachytherapy uses temporary radioactive source placement. Brachytherapy is appropriate for low-risk prostate cancer with small prostates and no urinary obstruction symptoms. The NCI reports excellent outcomes with brachytherapy for appropriately selected men, with side effect profiles similar to external beam radiation.
Hormone therapy (androgen deprivation therapy) lowers testosterone levels or blocks testosterone's effects, as prostate cancer growth is driven by male hormones. Hormone therapy options include LHRH agonists and antagonists (given by injection), oral anti-androgens, and surgical castration (orchiectomy, rarely performed). Hormone therapy is used in several settings: combined with radiation for intermediate and high-risk localized cancer (improving cure rates), for metastatic prostate cancer (slowing progression and controlling symptoms), and for biochemical recurrence after primary treatment.
According to the ACS, hormone therapy effectively controls prostate cancer but causes significant side effects including hot flashes, loss of libido and erectile dysfunction, fatigue, mood changes and depression, weight gain and muscle loss, bone density loss with increased fracture risk, and metabolic changes increasing diabetes and heart disease risk. These side effects accumulate with prolonged treatment, so timing and duration of hormone therapy are carefully considered.
Chemotherapy is generally reserved for metastatic castration-resistant prostate cancer (cancer that continues growing despite hormone therapy). Docetaxel and cabazitaxel are commonly used chemotherapy drugs that prolong survival in men with advanced disease. Newer targeted therapies and immunotherapies have emerged for advanced prostate cancer, including abiraterone and enzalutamide (blocking androgen production or action more completely than traditional hormone therapy), PARP inhibitors for men with BRCA mutations, and radium-223 for bone metastases.
Making Treatment Decisions: Balancing Cure and Quality of Life
Choosing among treatment options requires weighing cancer characteristics, potential cure rates, side effects, personal priorities, and overall health. For low-risk prostate cancer, active surveillance, surgery, and radiation all provide excellent long-term cancer control. The choice often comes down to personal preference regarding surveillance anxiety versus treatment side effects. Some men prefer immediate definitive treatment for peace of mind, while others prioritize avoiding or delaying treatment complications.
For intermediate and high-risk cancers, treatment is generally recommended, but surgery versus radiation (often combined with hormone therapy) offer similar cure rates. Factors favoring surgery include younger age, good health, preference for one-time treatment, and desire to know exact cancer extent through pathology. Factors favoring radiation include older age, medical conditions making surgery riskier, preference to avoid surgical recovery, and large prostates difficult to remove surgically.
The NCI emphasizes the importance of consulting physicians from multiple specialties—urology and radiation oncology—before deciding on treatment, as specialists may favor their own treatment approaches. Many cancer centers offer multidisciplinary clinics where patients see multiple specialists at once, receiving balanced information about all options.
Quality of life considerations should weigh heavily in treatment decisions, particularly for men over 65. If you have limited life expectancy due to other health conditions, aggressive prostate cancer treatment may not be warranted. The ACS notes that men who die with prostate cancer rather than from it haven't failed—they've lived full lives without undergoing treatment that wouldn't have extended their survival. For men with life expectancy under 10 years and low or intermediate-risk cancer, expectant management (monitoring without treatment unless symptoms develop) might be most appropriate.
Understanding prostate cancer—from the controversies surrounding screening to the range of treatment options from surveillance to surgery—empowers men over 65 to make informed decisions aligned with their health status, values, and goals. Most men diagnosed with prostate cancer survive long-term regardless of treatment approach, making quality of life a critical consideration in all prostate cancer decisions.